Self care Exam 2 - Allergic Rhinitis

Allergic Rhinitis is a systemic disease with prominent __ symptoms

nasal

Triggers of allergic rhinitis

1. indoor environmental allergens (house dust mites, roaches, mold)

2. outdoor environmental allergens (pollen, mulch)

4 phases of allergic rhinitis

1. Sensitization Phase

2. Early Phase

3. Cellular Recruitment Phase

4. Late Phase

Sensitization Phase

• follows initial allergen exposure

• IgE produced

• no symptoms

Early Phase

• occurs within minutes of allergen exposure

• release of mast cell mediators (histamine, proteases)

• release of inflammatory mediators (Prostaglandins, leukotrienes)

Cellular recruitment phase

• eosinophils are attracted to nasal mucosa

• release more inflammatory mediators

Late Phase

• begins 2-4 hrs after allergen exposure

• biggest symptom = mucus hypersecretion

3 classifications of allergic rhinitis

1. intermittent

2. persistent allergic rhinitis

3. episodic

symptoms occur 4 days or less per week or less than 4 weeks

Intermittent

symptoms occur more than 4 days a week AND 4 weeks

Persistent allergic rhinitis

occurs on exposure with potential allergen

episodic

Symptoms of allergic rhinitis

• bilateral

• sneezing

• watery nose

• itching of eyes, nose, and or palate

• nasal obstruction

• conjuctivitis

What two symptoms set allergic rhinitis apart from colds?

1. itching of eyes, nose, mouth

2. conjuctivitis

Treatment for allergic rhinitis

no cure but can reduce symptoms

Exclusions to self treatment of allergic rhinitis

1. children less than 12 yo

2. symptoms of otitis media, sinusitis, or bronchitis

3. symptoms of undiagnosed or uncontrolled asthma

Nonpharm therapy for allergic rhinitis

1. saline nasal sprays

2. Nasal Irrigation

relieves nasal mucosal irritation and dryness

nasal irrigation → neti pot

With neti pots, use ___. Do NOT use unfiltered water directly from tap

saline

Pharmacologic therapy for allergic rhinitis

1. Intranasal Corticosteroids (INCS)

2. Antihistamines

3. Decongestants

4. Cromolyn Sodium

Active ingredients of INCS

1. fluticasone propionate

2. mometasone furoate

3. triamcinolone acetonide

4. budesonide

MOA of INCS

1. inhibit multiple cell types and mediators

2. “Stop allergic cascade”

Uses of INCS

1. itchy nose, sneezing, runny nose, and congestion

2. itchy and watery eyes

Adverse effects of INCS

1. nasal discomfort/bleeding, sneezing, coughing

2. long term use causes changes in

   • vision

   • glaucoma

   • increased risk of infection

Use of INCS in pediatric pts

YES

• 2+ yo: fluticasone furoate, momentasone furoate, triamcinolone acetate

• 4+ yo: fluticasone propionate

• 6+ yo: budesonide

Use of INCS in PG pts

YES

Use of INCS in lactating pts

YES

Intranasal Corticosteroids Products

1. Rhinocort Allergy Spray — Budesonide

2. Flonase Allergy Relief — Fluticasone propionate

3. Nasacort Allergy — Triamcinolone acetonide

INCS takes __ days to start working therefore are not meant for quick relief

7

First generation antihistamines (sedating, nonselective)

• highly lipophilic

• crosses BBB

• anticholinergic effects

• brompheniramine, chlorpheniramine, diphenhydramine

Second generation antihistamines (nonsedating, peripherally selective)

• large, protein bound lipophobic molecules with charged side chains

• do not crosses BBB

• NO anticholinergic effects (does not enter brain)

• Fexofenadine, loratadine, cetirizine, levocetirizine

topical antihistamine

azelastine

MOA of topical antihistamine

1. competes with histamine at central and peripheral histamine type 1 receptor sites

2. prevents histamine recepter interaction and mediator release

Which generation of topical antihistamines inhibit the release of mast cell mediators?

second generation only

Which type of topical antihistamine blocks histamine

generation 1 and 2

Uses of topical antihistamines

1. itching, sneezing, runny nose

2. no effect on nasal congestion

Adverse effects of oral (first gen) antihistamines

1. CNS effects

• Depression → sedation, impaired performance

• stimulation → can develop into anxiety

2. Anticholinergic effects

• dry eyes and mucous membranes

• constipation

3. Photosensitizing

• use sunscreen

Adverse effects of Oral (second gen) antihistamines

1. sedation (cetirizine, levocetirizine)

Adverse effects of topical antihistamines

1. sedation

2. bitter taste, nasal stinging/burning, drowsiness

Drug interactions with antihistamines

1. amiodarone

2. MAOIs

Food interactions with antihistamines

1. fexofenadine and fruit juices (separate by 2 hours)

Disease interactions (first gen) antihistamines

1. glaucoma

2. asthma

What is the first line treatment for all patients with allergic rhinitis?

loratidine

Use of antihistamines in pediatric pts

First gen: NO

Second gen: YES

Use of antihistamines in geriatric pts

First gen: NO

Second gen: YES

Use of antihistamines in PG pts

YES

Use of antihistamines in lactating pts

NO

chlorpheniramine, fexofenadine, and loratadine are best options if needed

Systemic First Gen Antihistamine products

1. Chlor-Trimeton Allergy — chlorpheniramine

2. benadryl allergy tablets — diphenhydramaine

Systemic Second Gen Antihistamine Products

1. Zyrtec tabs — cetirizine

2. Allegra — Fexofenadine

3. Xyzal Allergy — Levocetirizine

4. Claritin — Loratidine

Nasal Antihistamine Products

1. Astepro Allergy Spray — Azelastine hydrochloride

Decongestants are used for ___ days max

3-7

MOA of cromolyn Sodium

Mast cell stabilizer

Uses of Cromolyn Sodium

1. prevent and treat symptoms

Adverse Effects of Cromolyn Sodium

1. sneezing, nasal stinging, burning

Dosing of Cromolyn Sodium

• pts 2+ yrs

• 1 spray in each nostil 3-6 times daily

Treatment of allergic rhinitis with cromolyn sodium is most effective when..

started before symptoms begin

Clinical improvement using cromolyn sodium

3-7 days (not for immediate relief)

Maximal therapeutic benefit of cromolyn sodium is reached after

2-4 weeks

Cromolyn sodium is safe for ___ pts

ALL

Cromolyn Sodium product

NasalCrom Spray

Refer pt with allergic rhinitis when …

1. symptoms do not improve after 1-2 weeks of treatment

2. signs and symptoms of bacterial infection develop